▪ 27 years old married woman

Lot 2, Purok 7 Barangay Saguin of San Fernando Pampanga

80 kilograms
5’4 feet tall
Roman Catholic
Tagalog and Kapampangan
4 year college course (entrepreneurship)
Accountant for 4 years; stopped working (pregnant to her
second child)
▪ Living with her mother-in-law, grandmother, and her first child.
• Their main source of income is from the work of her husband
since she is unemployed.
• Not willing to disclose any information about their daily and
monthly expenses
• Financially stable
Environmental factors
 Bungalow
 Residence surrounded by trees and tall grasses(air around their place
less polluted )
 Do not have any difficulties in transportation if any emergencies
Lifestyle
• Waking up at around 9:00 am to 10:00 pm
• Has someone to serve breakfast in bed (mother-in-law)
• Sits and rest in their living room while watching television
• Help around in their kitchen to prepare for lunch and dinner
• At 12:00 noon, her family eats lunch and then she would rest again in their living
room
seldom exercises
• Walk around their neighborhood for at least less than half an hour
• Sleep usually at around 10:00 pm to 11:00 pm
• Often wakes up every 2 hours in her sleep for some unknown cause
SEDENTARY LIFESTYLE
The client’s usual food choice during her
pregnancy
• Pineapple foods juices
• Sinangag or fried rice with fried eggs or longanisa (breakfast)
• Nilaga or sinigang and mainly eaten with two cups of rice(lunch)
• Fried seafood ( tilapia) and partner it with suite or boiled vegetables
• Soft drinks (meryenda)
• Would either eat less or skip dinner
• Filipino dish taken during lunch
• All meals is always taken with two glasses of water per meal
24 hour recall food diary during her stay in the
hospital
BREAKFAST NUMER OF SERVING KCAL CHO LIPIDS CHON

RICE ½ cup 171kcal 38g 0g 4g

STEAMED DORY ¼ cup 107 kcal 3g 0g 21g

DELMONTE PINEAPPLE 1 can 70 kcal 16g 0g 0g

LUNCH NUMER OF SERVING KCAL CHO LIPIDS CHON

LUGAW ½ cup 172kcal 35g 1.5g 1.5g

MAMON (MONDE) 1 pack 160 kcal 23g 50g 3g

WATER ½ Glass 0 kcal 0g 0g 0g

SNACKS NUMER OF SERVING KCAL CHO LIPIDS CHON

N/A N/A N/A N/A N/A N/A

DINNER NUMER OF SERVING KCAL CHO LIPIDS CHON

WATER 1 glass 0kcal 0g 0g 0g

SKYFLAKES 1 pack 120 kcal 16g 5g 2g

Maternal Obstetric Record
OB SCORE: G2 P2 - T2 P0 A0 L2 M0
Caesarean delivery on both child
First pregnancy in a baby boy born at 40 weeks gestation (now 4 years
old alive and well)
Second pregnancy in a baby boy also, born at 38 weeks gestation (now
alive and well)
No history of miscarriages
Antepartal / Prenatal Preparations
• Before childbirth she managed to exercise less than 30 minutes per
day especially during her 3rd trimester (walking around her
neighborhood every afternoon)
• client and family prepared for financial expenses
• didn't take any drugs or any vitamin supplement.
Significant Trimester Changes
FIRST TRIMESTER
• Striae Gravidarum (stretchmarks)
• linea nigra
• morning sickness three times a day for three months
• couvade syndrome for one day
• her breast where sensitive and tender
• Often urinate
• extreme fatigue and being emotional
• rarely sleeps in the afternoon and keeps on waking up every 2 hours in the
evening
Significant Trimester Changes
SECOND TRIMESTER
• extroversion where she likes to let people to physically caress her
baby bump
• daily cravings (pineapple juice and ice cream)
• saw obvious changes in her abdomen as a sign of further uterine
enlargement
• back pain due to sitting and standing
• feel the baby move though it is still not that evident to her
• sleeping schedule went back to normal
Significant Trimester Changes
THIRD TRIMESTER
• not experienced hemorrhoids or difficulties in urinating
• sleeping schedule changed again (because of Shortness of Breath)
• quickening at least 10 times a day (especially on the last weeks of her
gestation)
Family Health History: Genogram
History of Past Illness
Past health history related to the present condition
• previous caesarean section on her first child ( 40 weeks gestation)
• LMP is December 6, 2018
• EDC was on October 3, 2019
• Admitted on September 24, 2019
History of vaccines
• Acquired vaccination is anti-tetanus
• First vaccinated for her first child for 4 times
• Ob-gyne doctor decided to repeat her vaccination and start again
with her first dose to her second child
• For her second child she was vaccinated during the 7th month of
gestation followed by the second vaccination taken on the 8th month
of gestation and a scheduled date for the next dose on february of
the next year
History of Present Illness
• Admitted to our lady of mt. Carmel medical center (referrals from the
clinic of dr. Tolentino and dra. Sibug) for her emergency cesarean
section for cephalopelvic disproportion
• September 26, 2019
• 2:16 am lasted until 6:00 am
Physical Assessment General Survey
First Nurse Patient Interaction: (September 27, 2019 At 8:00 Am)
• Received in sitting position
• IV of D5LRS 1L on her left hand
• Hospital gown
• Alert and coherent
• She would be discharge depending upon the doctor’s visit and orders
• At 8:00 a.m. Temperature at 35.5oc, pulse rate of 98bpm, respiratory
rate of 20 bpm and blood pressure of 100/80 mmHg.
Physical Assessment General Survey
Second Nurse Patient Interaction: (September 27, 2019 At 10:00 Am)
• Received lying flat on bed
• Wearing hospital gown
• Alert and coherent
• Assisted to remove her IV line since her IV fluid is already finished
Physical Assessment General Survey
Final Nurse Patient Interaction: (September 27, 2019 at 12:00 noon)
• Received lying flat on bed
• Wearing hospital gown and is currently having her lunch meal along
with her mother-in-law
• Alert and coherent
• Vital signs were taken and recorded as follows: (at 12:00 noon)
temperature at 35.7oc, pulse rate of 96 bpm, respiratory rate of 20
bpm and blood pressure of 100/90 mmHg.
Bubble She Assessment
• Breast is full and firm with no discharges
• Breast is sometimes sensitive to touch
• Uterus is firm and no presence of bleeding
• No pain in urination
• Urinated and defecated once after administration of 1 tablet of dulcolax HS at
8:00 pm
• No prescence of lochia and vaginal discharges
• Absence of edema, eschimosis and any drainage
• No presence of any rashes as a sign of allergy to any medications
• Negative in homan’s sign since
• Not feeling stressed nor sadness, but is feeling physical weakness
Laboratory Procedure
CBC Test
Diagnostic and Laboratory Date requested/ Indication Results Normal Analysis and Interpretation
Procedure Date /Purpose Values
results in

WBC Date extracted: The complete blood 10.29 5-10 White blood cell count is
06/17/19 at 8:30am count (CBC) is a test increased, it is normal for some
Date results in: that evaluates the cells pregnant women because of
Segmenters 0.74 0.50-0.70
06/17/19 at 9:04 am that circulate in blood. physiologic stress induced by the
To identify and prevent pregnant state.
problems,
Lymphocyte 0.18 0.20-0.40

Monocyte 0.06 0.01-0.06

Diagnostic Procedure
Ultrasound Report
Diagnostic and Laboratory Date requested Indication Results Analysis and Interpretation
Procedure Date /Purpose
results in

Ultrasound Report: August 28,2019 It is used to help diagnose the BPD Single intrauterine
Trans causes of pain, swelling and (Biparietal Diameter) is 8.9 cm = 36 weeks pregnancy, breech
abdominal/ infection in the body's internal presentation with good
Biometry organs and to examine a baby in OFD (Occipitafrontal Diameter) is 11.4 cm cardiac & somatic activities,
pregnant women and the brain 34 weeks 6 days by
a CBC may
and hips in infants.
Eosinophils 0.02CI (Cephalic
0.01-Index) 77.9% composite aging: Placenta
be done left anterior, Grade II, high
before HC (Head0.05
Circumference) is 32.2 cm = 36 weeks lying; Normohydramnios;
pregnancy, & 2 days Sonographic estimated fetal
Hemoglobin if possible, 130 120-160 weight is appropriate for
at the AC (Abdominal Circumference) is 30.4 cm = 34 gestational age.
beginning of weeks & 2 days
pregnancy,
and one or FL (Femoral Length) is 6.4 cm = 32 weeks & 6
days
more times
during
SEFW (Sonographic Estimated Fetal Weight) is
pregnancy.
2393 g (Hadlock)
Hematocrit 245 150-350
Placenta is Left Anterior, Grade II , high lying
Platelets 4.6
AFI ( amniotic fluid index) is 17.5 cm ( deepest
vertical pocket)

Gender is male

Ultrasound EDC is on October 3, 2019

Anatomy and Physiology
Pathophysiology
Book-Based
Definition of the Disease

Cephalo-Pelvic Disproportion arises whenever the pelvic canal cannot

accommodate the fetal head, or is too narrow to allow the fetal head to
pass through for a spontaneous delivery.
 Predisposing and
Precipitating Factors
Precipitating Factors
Diet
An unbalanced diet can be a risk factor for pregnant women to undergo
cephalopelvic disproportion.
This may be due to the mothers consumption of food is exceeding the
maximum amount of daily required intake then the fetal growth will be
affected as well.
Precipitating Factors
Sedentary Lifestyle
Sedentary behavior during pregnancy may lead to unstable or
increased blood pressure and thus triglyceride process may affect the
intra-uterine environment and fetal development causing increase in
fetal birth size. Also, sedentary behaviors during pregnancy have been
associated with increased risk for gestational diabetes mellitus.
Precipitating Factors
Maternal Obesity
Obesity during pregnancy or also known as maternal obesity is defined
as a body mass index of greater than 30.
Excessive weight gain during pregnancy is typically defined as gaining
more than 1.5 pounds per week, and exceeding this rate may impact
the pregnancy and possibly cause CPD.
Precipitating Factors
Gestational Diabetes
Gestational diabetes mellitus, macrosomia is a common
accompaniment of CPD if not diagnosed correctly. Especially in women
with uncontrolled glycemia. Low insulin to possibly non insulin mother
would cause the excessive glucose to passby filtration or insulin binding
properties to lower glucose level and enter the fetus causing
macromegali, since unused glucose would be stored in the body.
Predisposing Factors
Age
The maternal age of the woman refers to how old the woman is when
she gives birth.
According to Lisonkova, Sarka, et al. (2017), “advanced maternal age” –
which, according to many experts, is as young as 35 – is a risk factor for
a variety of issues that can occur during pregnancy, labor, and delivery.
Predisposing Factors
Postmature baby
According to Norwitz (2019), Postterm pregnancy which is also called
as postdate pregnancy, prolonged pregnancy, and postmaturity
pertains to a pregnancy that extends beyond the standard gestation
time of 37 to 42 weeks. In cases of postterm pregnancy, the fetus may
be too large because it became over-developed in the womb, making
delivery difficult and increasing the risk for birth trauma, brain bleeds,
hypoxic-ischemic encephalopathy (HIE), cerebral palsy, seizures, and
other forms of brain damage (1).
Predisposing Factors
Fetal Position
Before delivery, it is critical that the fetus is in this standard vertex
presentation and within the normal range for weight and size.
This helps ensure the safety of both baby and mother during labor.
Any position other than vertex position is abnormal and can make
vaginal delivery much more difficult or sometimes impossible.
(Moldenhauer, 2018).
Predisposing Factors
Increased Fetal Weight
Risk factors for fetal macrosomia include mothers who are maternal
obesity or overweight (more than 8 pounds, 13 ounces (4,000 grams),
regardless of his or her gestational age.
Predisposing Factors
Polyhydramnios
Polyhydramnios is also called as hydramnios or amniotic fluid disorder,
is a pregnancy complication in which there is an abnormal increase in
the volume of amniotic fluid.
According to Hamza (2013), symptoms and complications of
polyhydramnios include maternal breathing difficulties, preterm labor,
premature rupture of membranes (PROM), unusual fetal presentation,
umbilical cord prolapse, and postpartum hemorrhage.
Predisposing Factors
Previous Caesarean delivery
Women who have had a previous caesarean delivery are at increased
risk of unexplained stillbirth in the second pregnancy.
A mother may have the risk of having a large fetus.
Predisposing Factors
Multiparity
Multiparity which refers to a mother that has previously been
pregnant.
Woman who are multiparas, tend to be more likely to be of old age
which might be the reasons for increased morbidity and mortality. It
can have many medical and obstetrical complications because of its risk
factors in labor and delivery.
Pathologic Changes
During labor and delivery of a CPD patient since it would be difficult for
the women to deliver the fetus vaginally though attempted, most
physicians would allow labor to progress for far too long. Labor is a
trying time for the baby and if this was not successful, physicians may
react by administering Pitocin in an effort to speed up delivery. Pitocin
is a drug used to cause contraction of the uterus to start labor and
increase the speed of labor. If the uterine contractions fail to have
progressive dilation and effacement of cervix, emergency caesarean
section is done.
Signs and Symptoms
Prolonged 1st stage of labor
Cervix dilates from 6cm to 10cm
Cervix dilates to prepare for birth: It starts to dilate (open) and efface (thin
out) from 6cm to 10 cm as to pave way for the fetus to come out to the birth
canal.
Intense contraction
Contractions are when the muscles of your uterus get tight and then relax.
Intense contraction happens as the uterine muscles exert more effort to try
and deliver the baby.
Cramps
Cramping typically occurs when the uterus expands, causing the ligaments
and muscles that support it to stretch. The muscles stretching out results to
pain. It is caused by growing uterus, and gives sharp piercing or dull pulling
feeling. Some women experience sharp, piercing pain in the vagina.
Fatigue
Fatigue and "nesting instinct" where the mother’s body requires
adequate energy for the process of labor and delivery and thus more
energy is consumed.
Water breaking
The amniotic fluid-filled membrane will rupture thus there is a release
of water as a sign of pending labor.
Clear, pink, bloody discharge from vagina
Vaginal discharge changes color and consistency loss of mucous plug
and the thickened, pinkish discharge is called bloody show and is a
good indication that labor is imminent, but without contractions or
dilation of three to four centimeters.
Signs and Symptoms
Cephalopelvic Disproportion
Labor extends beyond 6 to 18 hours
Prolonged labor or arrested labor is define by Friedman as the cervical
dilation of less 1.2 cm/hour for a woman’s first pregnancy, and less
than 1.5 cm/hour for a woman who has previously given birth. It is due
to difficulty of the fetus to descent in the pelvic area.
Dehydration and exhaustion of the mother
Due to prolonged labor there would be an insufficient supply of fluid
and energy to the patient. This is a result of inadequate progress of
labor due to poor uterine action in the first stage, and poor maternal
effort in bearing down during the second stage of labor.
Pain around the back, sides, and thighs
The pain that can be felt as strong cramping in the abdomen, groin and back
as well as an achy feeling is due to the pain during labor that is caused by
contractions of the muscles of the uterus and by pressure on the cervix.
Some women experience pain in their sides or thighs as well.
Increased heart rate of the mother
Increasing prevalence of sedentary behaviour and lack of aerobic fitness
may reduce heart rate reserve during labour. Thus, the lack of aerobic fitness
may limit pushing efforts during childbirth and represents increased
cardiovascular strain and risk.
Shoulder Dystocia
Shoulder Dystocia may occur when the head of the fetus was successfully
delivered but get stuck because the shoulder of the fetus is unable to past
through. It may be due to being stuck in the mother’s pelvis for being too
small for the fetus size or that the fetus is too large to pass through.
Pathophysiology
Client-Centered
Definition of the Disease
Cephalo-Pelvic Disproportion arises whenever the pelvic canal cannot
accommodate the fetal head, or is too narrow to allow the fetal head to
pass through for a spontaneous delivery. The abnormality of the client,
is that the size of the pelvic canal of the mother cannot accommodate
the normal size of the fetal cranium; the pelvic canal is too narrow for
the fetal head. However the resulting condition, CPD, becomes an
abnormality in that the fetal head cannot progress through the pelvic
canal. It resulted to an emergency C-section as the attempted vaginal
delivery was not successful
Precipitating Factors
Sedentary Lifestyle
The client is considered to have a sedentary behavior during her
pregnancy. Her usual daily routine was mainly sitting and resting. She
seldoms exercises but when she does it only involves walking that last
for less than an hour a day. This may have contributed to the intra-
uterine environment and lead to CPD.
Maternal Obesity
The client heights is 5 feet and 4 inches or 162.56 centimeters weighs
80 kilograms. Her BMI index is 30.5 which is in the category of obese
for adults in relation to her height.
Predisposing Factors
Previous Caesarean delivery
The client has a history of previous caesarean section when she had her
first child at 40 weeks of gestation. She still attempted to deliver
vaginally but was unsuccessful.
Multiparity
The client has previously been pregnant and this is her second
pregnancy too date. The age gap of both her child is 4 years apart that
were both delivered at term.
Pathologic Changes

During her labor and delivery they attempted to vaginally deliver her
child. Around the time where she successfully delivered the head of the
fetus, the shoulder got stuck resulting to a failure in vaginal delivery of
her child. She then opted to have a emergency caesarean section.
Signs and Symptoms for Prolonged 1st Stage of
Labor
Intense contraction
The client stated that she experienced intense contraction during her
labor.
Cramps
The client felt cramps in her abdomen area during her labor. She
described the pain as sharp with piercing feeling. She also added that
her vagina was also painful.
Signs and Symptoms for Prolonged 1st Stage of
Labor
Fatigue
The client reported feeling of extreme weakness during her labor as
she can barely stand.
Water breaking
The client stated the she experienced the water breaking and was
unable to stand for awhile because of it. The pain followed after.
Clear, pink, bloody discharge from vagina
Her vaginal discharge during her labor was viscous accompanied with
blood.
Signs and Symptoms for Cephalopelvic
Disproportion
Pain around the back, sides, and thighs
The client described the pain in her abdomen as spreading around her
back and groin area. She felt piercing pain on these areas during her
labor.
Shoulder Dystocia
The client stated that during her labor she was able to successfully
deliver the head of the fetus but she reported that she was unable to
naturally push the fetus further resulting for the fetus shoulder to be
stuck. She then decided to undergo emergency c-section.
Medical Management
IV Therapy
Medical Date ordered General Description Indication(s) Client’s response to
Management/ Date performed or the treatment
treament Date changed Purposes

Intravenous September 24, 2019 Adults and Children Ordered to be given Client did not feel
Administration of at 11:00 am. age 13 and older: I.V. to lower any irritation or any
Cefuroxime Axetil, 750 mg to 1,500 mg possibility of Skin symptoms of
1,000mg – 1500mg Cefuroxime sodium structure infection possible infection on
I.V. I.V. for post op post-operative site.
Serious lower operation.
respiratory tract
infection, UTI, skin
or Skin- structure
infection, Bone or
joint-Infection.

Nursing Responsibilities include: Assessing patient for signs and symptoms of infection prior to and
throughout therapy and test for any allergic reaction.
 Nubain is used to Nubain cocktailed Client is in relaxed
Administer September relieve moderate to with Phenergan
Cocktail of condition to softly
severe pain. It may
Nubain Lamp
24, 2019 at also be given before
ordered to be given
to act as analgesic
numb sensation
and after a surgery or and tinging ling on
infused with 12:30pm. with a general
for post-operative
foot with slight
anesthesia before an patients
Phenergan discomfort on
operation. It may also
Lamp be used to relieve pain operative site,
to be while giving birth. although
manageable.
administered Phenergan, prevents
motion sickness, and
via Intravenous treats nausea and
diluted vomiting or pain after
surgery. It is also used
Through IV as a sedative or sleep
Fluid aid.

Nursing Responsibilities include: Assess type, location, and intensity of pain before and after 30 minutes (peak) after IV
administration. Assess for hypersensitivity to previous analgesics and antihistamines before administration.
Pharmacotherapy
Generic Name Date ordered Route of administration/ Indication/s Mechanism of action Client’s response to the
Brand Name Date performed Frequency Medication
Date changed

Mefenamic acid; 09/24/19 Per orem, q8, 50 mg/tab It is used for the short Binds the Client is relieved of pain
Tonstel term treatment of prostglandinsynthetase after taking the medication
mild to moderate receptors COX-1 and and no any allergic reaction
pain from post op COX-2, inhibiting the
operation. action of prostaglandin
synthetase. As these
receptors have a role as
a major mediator of
inflammation and a role
for prostanoid signaling
in activity- dependent
plasticity, the symptoms
of pain area temporarily
reduced
Nursing Responsibilities include: Assess patient for any signs of allergic reaction or

hypersensitivity. Assess pain using appropriate pain scale tools to identify if the

medication is helping to relieve the patient’s pain.

Bisacodyl; 09/25/19 Oral Admnistration HS (8pm) Postpartum care after Stimulates peristalsis, alters After one hour of medicine
Dulcolax at 8 pm surgery to evacuate fluid and electrolyte administration the client was able
bowel transport producing fluid to defecate once.
accumulation in the colon

Nursing Responsibilities include: Assess patient for abdominal distention, presence of bowel sounds, and usual
pattern of bowel function. Also assess color, consistency, and amount of stool produced.
Cefuroxime axetil; 09/24/19 PO, BID,q8, 50 mg/tab Ordered to be given PO Bactericidal agent that acts Client did not feel any irritation or
Cefurex at 8 pm to lower susceptibility by inhibition of bacterial cell any symptoms of possible infection
to skin structure wall syntesis. Has presence on post-operative site.
infection for post op of some B- lactamases, both
operation. penicillinases and
cephalosporinases, of gram-
negative and gram- positive
bacteria.

Nursing Responsibilities include: Monitor injection site for pain, swelling, and irritation. or excessive injection site
reactions to the physician. Also monitor signs of allergic reactions and anaphylaxis, including pulmonary symptoms
(tightness in the throat and chest, wheezing, cough dyspnea) or skin reactions (rash, pruritus, urticaria). Notify physician
or nursing staff immediately if these reactions occur.
Report prolonged
Nalbuphine 09/24/19 Per orem, q4, 50 It is indicated Binds to opiate Client is relieved of pain
Nubain mg/tab for the receptors in the after taking the
management of CNS. Alters the medication and no any
moderate to perception of and allergic reaction
pain severe response to painful
enough to stimuli while
provide producing
analgesia during generalized CNS
labor depression. In
Nursing Responsibilities include: Assess symptoms of respiratoryaddition,
depression, including decreased respiratory rate,
has partial
antagonist
confusion, bluish color of the skin and mucous membranes (cyanosis), and difficult, labored breathing (dyspnea).
properties, which
may result in opioid
Additionally, Use appropriate pain scales (visual analogue scales, others) to document whether this drug is successful
withdrawal in
physically
in helping manage the patient's pain.
dependent patients.
Diet Therapy
Type of Diet Date ordered General Indication Client’s response to the
Date performed Description & Purpose Medication
Date changed
Soft Diet 09/25/19 The delicate eating This diet is The client was able to
routine points of indicated for the swallow and chew food easily
confinement or takes out client since she is and did not feel any hunger.
nourishments that are not ready for foods
difficult to bite and of normal
swallow, for example, consistency or with
crude leafy foods, chewy too many spices
breads, and intense after post op
meats. surgery.
General Liquid 09/24/19 A full fluid eating This diet is to The client was able to
Diet routine is allow the client easily ingest food
incorporating all to ingest food without having to chew.
nourishments that easily and is
are fluid or will go to recommended as
fluid at room a short term diet
temperature, or after post op
soften at body surgery.
temperature.
Clear Liquid 09/24/19 A clear liquid diet is This diet was The client did not feel
Diet often used before required to the famished or empty
tests, procedures client as she before her surgery.
or surgeries that would undergo
require no food in surgery.
your stomach or
intestines.
DAT 09/25/19 This particular diet is The client is The client was able to eat
(Diet as Tolerated) only given when client allowed to choose food that she wants except
can now tolerate any the food she can the prohibited food to her.
food she desires that is have after her
nutritious, if this will not surgery.
lead to any complications
and if the client needs
further monitoring for
lab test.

Nursing Responsibilities include: Advised patient to eat food

specially protein food 2-3 times per day such as meat, poultry,

fish, eggs, dairy, beans, nuts and seeds as this helps in tissue

repair. Advised patient to include pureed fruits, such as

applesauce and pureed vegetables diluted into soups, such as

strained pumpkin puree in a cream soup.

Exercise
Type of Exercise Date ordered General Indication Client’s response to the
Date performed Description & Purpose Medication
Date changed

High Back Rest 09/24/19 Much back pain in To allow the client The client was relieved from back
pregnancy is related to the relieve the back pain pain.
strain in the back from the and lessen the strain
weight of carrying the fetus. in the back area.
Dangle Legs 09/24/19 The dangle allows To allow the The length of gving
the shifting of the client to have birth of the client was
pelvis out of the full mobility of reduced.
way of the fetus the pelvis
who is assumed to during
be in the center of contraction.
the downward
pressure of the
contraction on the
Nursing Responsibilities include: Advised patient to train
fetus head.
the body to stand, walk sit, and lie in positions where the

least strain is placed on your back. Assist patient in any

form of exercise to ensure that no injuries or accident may

happen during the exercise. Involve the S.O.s in assisting

the patient in conducting these exercises.

Nursing Care Plans
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Acute pain An unpleasant Short Term: Independent: Goal Met:
“Pagumuupo ako related to sensory and After 1-2 hr of Established rapport. To have a good After 2hrs of
kumikirot yung disruption of skin emotional nursing nurse-client nursing
sugat kaya hinihiga and tissue experience with intervention, relationship intervention, the
ko na lang” as secondary to actual or potential patient will patient verbalized
verbalized by the caesarean tissue damage, or verbalize decrease Assessed quality, To establish baseline pain decreased
patient. section. described in terms intensity of pain characteristics, severity data for comparison from a scale of
of such damage; from 7/10 to 3/10. of pain. 7/10 to 3/20 as
Objective: sudden or slow evidenced by no
Pain scale= 7/10 onset of any Instructed to put pillow To protect the area evident facial
intensity from mild on the abdomen when of the incision to grimace.
Facial grimace to severe with an moving. improve comfort.
anticipated or To relieve stress and
Positioning to ease predictable end. Instructed patient to promote relaxation.
pain do deep breathing and
coughing exercise.
Calm environment
Provided diversionary helps to decrease the
activities. Initiate ankle anxiety of the patient
pumping, active lower and promote
extremity ROM, and likelihood of
walking decreasing pain.
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Activity Intolerance Insufficient Short Term: Independent: Goal Met:
“Di ko pa kayang related to physiological or After 2 hr sof nursing Evaluate the client’s To provide baseline After 2 hrs of nursing
tumayo dahil immobility/bed rest psychological energy intervention, patient actual and perceived information intervention, the
sumasakit sugat ko” secondary to to endure or complete will identify limitations and severity of patient was able to
as verbalized by the caesarean section required or desired alternative ways to deficit light of usual status identify alternative
patient. daily activities maintain desired ways to maintain
activity level. Ascertain the client’s desired activity level.
Objective: ability to stand and move
Inability to stand or about To determine current
sit status
(Immobility) Identify activity needs
versus desires To evaluate
Generalized weakness appropriateness
Assist with activities and
Painscale of 7/10 provide/monitor client’s To protect client from
use of assistive devices injury
such as wheelchair

Increase exercise/activity
levels gradually

Collaborative: To conserve energy

Refer to appropriate
resources for assistance
and/or equipment needed
To sustain activity level
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Impaired Skin Integrity Altered epidermis and/or Short Term: Independent: Goal Met:
“May hiwa ako sa may related to alteration in dermis. After 8 hours of nursing Established rapport. To have a good nurse-client After 2hrs of nursing
tiyan dahil na CS ako” as skin integrity secondary interventions, the patient relationship intervention, the patient
verbalized by the patient. to Caesarean section. will be able to participate To determine unusual ties was able to display timely
in prevention measures Inspect skin on daily basis and and report it to physician for healing of skin lesions/
Objective: and treatment program obseve for changes and prompt treatment. wounds without
Incision site on abdomen unusualities This will assist body’s complication.
Long Term: natural process of repair.
Destruction of skin layers After 3 days of nursing Keep the area clean, carefully
interventions, the patient dress wound, support incison,
Desruption of tissue will be able to display prevent infection
layers. timely healing of skin
lesions/ wounds without Encourage client to Maintaining clean, dry skin
complication. demonstrate good skin provides a barrier to
hygiene, e.g., wash thoroughly infection. Patting skin dry
and pat dry carefully after instead of rubbing reduces
teaching. risk of dermal trauma to
fragile skin

Collaborative:
Provide optimum nutrition
such as increased protein
intake.
To provide a positive
nitrogen balance to aid in
healing.
To prevent post operative
wound complication

Dependent:
Administer medication as per
doctor’s order.
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Risk for functional Vulnerable to infrequent or Short Term: Independent: Goal Met:
None Constipation difficult evacuation of feces, After 8 hours of nursing Ascertain normal bowel This is to determine the normal After 8º of nursing
which has been present for intervention, the patient will functioning of the patient, about bowel pattern interventions, the patient
Objective: nearly 3 out of the prior 12 be able to establish or how many times a day does she was able to defecate once
Patient has not yet months, which may regain a normal bowel defecate after administration of
eliminated since delivery compromise health. functioning as evidenced by dulcolax as prescribed by
defecation at least once. Encourage intake of foods rich in the doctor.
Absence of bruit sounds fiber such as fruits To increase the bulk of the
Long Term: stool and facilitate the passage
Normal pattern of bowel After 2-3 days of nursing through the colon
has not yet returned intervention, patient will
demonstrate behaviors or Promote adequate fluid intake. To promote moist soft stool
lifestyle changes to prevent Suggest drinking of warm fluids,
developing problem especially in the morning to
stimulate peristalsis

However, since she has had

cesarean, also encourage
adequate rest periods

Dependent: To avoid stress on the cesarean

Administer bulk-forming agents incision/ wound
or stool softeners such as
laxatives as indicated or
prescribed by the physician
To promote defecation
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Risk for infection Vulnerable to invasion Short Term: Independent: Patient is expected to
None and multiplication of After 4 hours of Established rapport. To have a good nurse- be free of infection,
pathogenic organisms, nursing intervention, client relationship as evidenced by
Objective: which may patient will be able to Moist from drainage can normal vital signs and
Incision site on compromise health understand causative Inspect dressing and be a source of infection absence of purulent
abdomen factors, identify signs perform wound care drainage from
of infection and To monitor signs of wounds, incisions,
Dressing is dry and report them to health Monitor Elevated infection and tubes.
intact care provider temperature, Redness,
accordingly swelling, increased pain,
or purulent drainage at
Long Term: incisions
After 2-3 days of
nursing intervention, Wash hands and teach Washing between
patient will achieve other caregivers to wash procedures reduces the
timely wound healing, hands before contact with risk of transmitting
be free of purulent patient and between pathogens from one
drainage or erythema, procedures with patient. area of the body to
be afebrile and be another
free of infection.
Dependent: Antibiotics have
Administer antibiotics as bactericidal effect that
per doctor’s order. combats pathogens
Conclusions
There are more factors involve in diagnosis a patient for Cephalopelvic
disproportion. When risk factors for CPD are present, it is essential that the
physician monitor the mother and baby very closely and be prepared for a C-
section delivery. It is important that aside from examining the fetal size and
the mother’s pelvic condition in assessing for the possibility of CPD, it is
crucial to always include the patients diet, lifestyle, and other illness that
may contribute to failure of vaginal delivery such as gestational diabetes and
maternal obesity. Additionally, the attending physicians should be certain if
they are dealing with a CPD patient to schedule a Caesarean delivery ahead
of time. In cases where they are hesitant if it is indeed a true CPD patient
and attempted the vaginal delivery, they should be prepared for an
emergency C-section while to avoid birth injuries that may result from
excessive pulling/pressure.
Recommendations
Since Cephalopelvic disproportion is not considered a disease or an
abnormality on the fetus, it is necessary that the medical professionals
involved in the examining of the condition of the mother and the fetus
is to ensure that they could identify the cause or the factor that is
preventing the fetus from making its way through the birth canal, but
more importantly to diagnose what exactly the problem is. An
appropriate intervention for an abnormal fetal presentation may do
more harm than good in a case of a true cephalopelvic disproportion.
This is for the reason that failure to successfully deliver the baby in a
CPD patient may lead to fetal distress and maternal injury.
Thank You!!!